Ectopic Pregnancy

Definition | Symptoms and Signs | Examination | Management | Diagnosis and Treatment in Secondary Care | References

Definition

Ectopic Pregnancy occurs when a fertilised egg implants outside the uterine cavity, most commonly in the fallopian tube. It is a potentially life-threatening condition if not promptly diagnosed and treated, as it can lead to tubal rupture and intra-abdominal bleeding.

Symptoms and Signs

Be aware that ectopic pregnancy can present with a wide variety of symptoms and signs, which may be atypical and can resemble those of other more common conditions (such as urinary tract infections and gastrointestinal conditions).

Suspect ectopic pregnancy in a woman of childbearing potential who presents with any of the following:

Common Symptoms:

• Abdominal or pelvic pain.
• Amenorrhoea or missed period.
• Vaginal bleeding (with or without clots).

Less Common Symptoms:

• Breast tenderness.
• Gastrointestinal symptoms (such as diarrhoea and/or vomiting).
• Dizziness, fainting, or syncope.
• Shoulder tip pain.
• Urinary symptoms.
• Passage of tissue.
• Rectal pressure or pain on defecation.

Be aware that symptoms generally appear 6–8 weeks after the last normal menstrual period (or much later for a non-tubal ectopic pregnancy). Clinical presentation can be highly variable and ranges from no symptoms to cardiovascular collapse.

Common Signs:

• Abdominal tenderness.
• Pelvic tenderness.
• Adnexal tenderness.

Other Signs:

• Cervical motion tenderness.
• Rebound tenderness or peritoneal signs.
• Pallor.
• Abdominal distension.
• Enlarged uterus.
• Tachycardia (more than 100 beats per minute) or hypotension (less than 100/60 mmHg).
• Shock or collapse.
• Orthostatic hypotension.

Be alert for symptoms and signs of tubal rupture and intra-abdominal bleeding, such as:

• Vomiting and diarrhoea may be the presenting symptoms of abdominal bleeding.
• Shoulder pain may be caused by irritation of the diaphragm due to leakage of blood from the implantation site.
• Pallor, tachycardia, hypotension, and shock or collapse may indicate tubal rupture and severe bleeding.

Examination

If immediate hospital transfer is not indicated, confirm pregnancy with a urine pregnancy test (if not already done). Take a medical history and ask about:

• Signs and symptoms.
• Sexual activity and use of contraception.
• Date of the last menstrual period and when symptoms started.
• Date of the positive pregnancy test (if one has been done).
• Risk factors for ectopic pregnancy.

Exclude the possibility of ectopic pregnancy, even in the absence of risk factors, as in about a third of cases there are no identifiable risk factors. Perform an abdominal examination. Perform a gentle pelvic examination if there is no abdominal pain and tenderness. Do not palpate for an adnexal or pelvic mass as this may increase the risk of rupture of an ectopic pregnancy if present.

Management

• Refer women who are haemodynamically unstable (including pallor, tachycardia, hypotension, shock, and collapse), or in whom there is significant concern about the degree of bleeding or pain, directly to Accident and Emergency.
• Refer women immediately to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) for further assessment (with urgency depending on clinical judgement) if they have a positive pregnancy test and any of the following are present on examination:
  • Pain and abdominal tenderness.
  • Pelvic tenderness.
  • Cervical motion tenderness.
• Refer women to an early pregnancy assessment service (with urgency depending on clinical judgement) if they have bleeding or other symptoms and signs of early pregnancy complications and they also have any of the following:
  • Pain.
  • A pregnancy of 6 weeks' gestation or more.
  • A pregnancy of uncertain gestation.
• Use expectant management for women with a pregnancy of less than 6 weeks' gestation who are bleeding but not in pain and who have no risk factors, such as a previous ectopic pregnancy. Advise these women:
  • To return if bleeding continues or pain develops.
  • To repeat a urine pregnancy test after 7 to 10 days and to return if it is positive.
  • That a negative pregnancy test means that the pregnancy has miscarried.
• Refer women who return with worsening symptoms and signs that could suggest an ectopic pregnancy to an early pregnancy assessment service (or out-of-hours gynaecology service if the early pregnancy assessment service is not available) for further assessment (with urgency depending on clinical judgement).
• For all women referred to an early pregnancy assessment service (or out-of-hours gynaecology service):
  • Explain the reasons for the referral and what she can expect on arrival.
  • Arrange follow-up and offer appropriate support, information, and advice.
  • Provide all women, and (with her consent) her partner, specific evidence-based information in a variety of formats. This should include (as appropriate):
    • When and how to seek help if existing symptoms worsen or new symptoms develop, including a 24-hour contact telephone number.
    • What to expect during the time she is waiting for an ultrasound scan.
    • What to expect during the course of her care (including expectant management), such as the potential length and extent of pain and/or bleeding, and possible side effects; this information should be tailored to the care she receives.
    • Information about postoperative care (for women undergoing surgery).
    • What to expect during the recovery period – for example, when it is possible to resume sexual activity and/or try to conceive again, and what to do if she becomes pregnant again; this information should be tailored to the care she receives.
    • Information about the likely impact of her treatment on future fertility.
    • Where to access support and counselling services, including leaflets, web addresses, and helpline numbers for support organisations.
    • Offer the woman the option of a follow-up appointment with a healthcare professional of her choice.

Diagnosis and Treatment in Secondary Care

Diagnosis

• Transvaginal Ultrasound: The diagnostic tool of choice for a suspected ectopic pregnancy. It is used to identify the location of the pregnancy and whether there is a fetal pole and heartbeat.
• Transabdominal Ultrasound: May be used in some cases (for example, in women with an enlarged uterus or other pelvic pathology such as fibroids or an ovarian cyst, or if a transvaginal scan is unacceptable), but imaging is of poorer quality.
• Magnetic Resonance Imaging (MRI): May be used as a second-line investigation tool in certain cases, for example, if the diagnosis of a caesarean scar ectopic pregnancy is equivocal and there is local expertise in MRI diagnosis.
• Serum Human Chorionic Gonadotrophin (hCG): In women with pregnancy of unknown location (PUL), defined as a positive pregnancy test but no visible evidence of the location of the pregnancy on an ultrasound scan, measurements of serum hCG may be used to determine subsequent management. However, clinical symptoms are of more significance than hCG levels.
• Repeat Transvaginal Scans, Serial hCG Levels, and Laparoscopy: May be used to confirm the diagnosis.

Treatment

After an ectopic pregnancy has been confirmed, treatment options include expectant management (watchful waiting), medical management, and surgery. The choice of treatment will depend on factors such as the haemodynamic stability of the woman, the site of implantation of the ectopic pregnancy, the risk of tubal rupture, serum hCG level, the level of pain the woman has, and the acceptability of the method of treatment to the woman.

• Expectant Management: An option for a few women who are clinically stable and pain-free. Active intervention will be considered if symptoms of ectopic pregnancy occur or if levels of serum hCG fail to decrease at an acceptable rate.
• Medical Management: Involves the use of drug treatment, most commonly parenteral methotrexate. It is offered first line to women who are able to return for follow-up and who have all of the following:
  • No significant pain.
  • An unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.
  • Serum hCG level less than 1500 IU/L.
  • No intrauterine pregnancy (as confirmed on an ultrasound scan).
• Surgical Management: Performed by means of salpingectomy or salpingotomy, either laparoscopically or by open surgery. It is offered first line to women who are unable to return for follow-up after methotrexate treatment or who have an ectopic pregnancy and any of the following:
  • Significant pain.
  • An adnexal mass of 35 mm or larger.
  • A fetal heartbeat visible on an ultrasound scan.
  • Serum hCG level of 5000 IU/L or more.
• Combined Methotrexate or Surgical Management: A choice of either methotrexate or surgical management is offered to women with an ectopic pregnancy who have a serum hCG level of at least 1500 IU/L and less than 5000 IU/L, are able to return for follow-up, and meet all of the following criteria:
  • No significant pain.
  • An unruptured ectopic pregnancy with an adnexal mass smaller than 35 mm with no visible heartbeat.
  • No intrauterine pregnancy (as confirmed on an ultrasound scan).
• Follow-Up: All women (except those who have had a salpingectomy) will be followed up according to local protocols to ensure that serum hCG levels decrease at an acceptable rate until non-pregnant levels are reached.
• Anti-D Immunoglobulin: Offered to all rhesus-negative women who have had surgical removal of an ectopic pregnancy.

References

1. NHS (2024) Ectopic Pregnancy. Available at: https://www.nhs.uk/conditions/ectopic-pregnancy/ (Accessed: 24 June 2024).
2. National Institute for Health and Care Excellence (2024) Ectopic Pregnancy and Miscarriage: Diagnosis and Initial Management. Available at: https://www.nice.org.uk/guidance/ng126 (Accessed: 24 June 2024).
3. Royal College of Obstetricians and Gynaecologists (2024) Green-top Guideline No. 21: Diagnosis and Management of Ectopic Pregnancy. Available at: https://www.rcog.org.uk/en/guidelines-research-services/guidelines/gtg21/ (Accessed: 24 June 2024).